ORIGINAL ARTICLE

Repeated Tourniquet Testing as a Diagnostic Tool in

Dengue Infection
o Norlijah, MRCP*, A Nor Khamisah, MDUPM**, A Kamarul, M Paeds*** S Mangalam, FRCPath****
*Faculty of Medicine and Health Sciences, University Putra Malaysia, "Ministry of Health, Malaysia, "'Institute of Paediatrics, Hospital
Kuala Lumpur, ''''''Department of Pathology, Hospital Kuala Lumpur, Malaysia

Introduction

The geographical spread, incidence and severity of

dengue fever (DF) and dengue haemorrhagic fever
(DHF) are increasing in the Americas, South-East Asia,
the Eastern Mediterranean and the Western Pacific.
Some 2,500 million to 3,000 million people live in areas
where dengue viruses can be transmitted.
It is
estimated that 50 million infections occur each year,
with 500,000 cases of DHF and at least 12,000 deaths'.
The hallmark that differentiates DHF and dengue fever
is the increased capillary permeability and
haembconcentration in DHF.
Increased capillary
leakage will result in plasma leakage and subsequent
hypotension',
Thrombocytopaenia,
coagulation

abnormalities and clinical bleeding of varying severity

are features of DHF and DSS, but may also occur in DP,
The tourniquet test has been recommended as the
initial screening procedure of patients with suspected
DHF4 , This 5 to 10 minute platelet-activity haemostasis
test is to assess fragility of capillary, walls and to
evaluate platelet number and function, The World
Health Organisation (WHO) indicated a positive
tourniquet test as an important clinical manifestation
particularly in DHF grade 1. Previous studies have
evaluated the role of tourniquet test in dengue
infection, performed as a single testing at the time of
first presentation; and showed that it was specific and
had a high positive predictive value but was not

This article was accepted: 3 October 2005

Corresponding Author: Norlijah Othman, Department of Human Growth & Development, Faculty of Medicine & Health Sciences,
UPM 50586 Jolon Masjid, Kuala Lumpur
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Repeated Tourniquet Testing as a Diagnostic Tool in Dengue Infection

sensitive5,6. However, there is a dearth of data on the

formal evaluation of repeated, frequent tourniquet
testing as a diagnostic utility for dengue infection. The
aim of this study was to evaluate the validity of
repeated tourniquet test as an indicator of dengue
infection.

Materials and Methods

Subject enrollment
Previously healthy children presented to a tertiary
children's hospital in Kuala Lumpur between June and
August 2001 were eligible for entry into this study if
they met the following criteria: age between 6 months
and 12 years, a clinical suspicion diagnosis of dengue
infection/DHF using WHO criteria at initial presentation
on admission. The provisional diagnosis of DHF was
made in all of the cases based on clinical assessment,
which comprised of patient's symptoms and examiner's
findings. Informed verbal consent was obtained from
parents or legal guardians of each child before
enrolment.
Study design
At the time of admission to the hospital, subjects and
their parents were interviewed to collect demographic
data and medical history. The tourniquet test was
carried out by NKA, a third-year medical student, on
alternating arms each day for all subjects from the time
of enrolment. An appropriate sized blood pressure cuff
was chosen according to the length of the upper arm
of the subject. The cuff was then inflated to a point
midway between the diastolic and systolic pressure and
maintained for the next 5 minutes. The number of
petechiae that appeared on the flexor aspect of the
forearm just distal to the antecubital fossa was
determined. As stipulated by the WHO criteria, the test
was considered positive when 20 or more petechiae
per 2.5cm (l inch) square were observed after the
tourniquet was released3 If the test was negative, the
test would be repeated the next day until the subject
was discharged from the hospital or until > 20
petechiae were recorded on anyone day. Children
presenting with shock were resuscitated first with
parenteral fluids and the tourniquet test was performed
after adequate circulation had been achieved.
The clinical and laboratory results were recorded in
standardized data notes and later transferred to a
computer database. In this study, the results of the
tourniquet tests were not validated by a second
independent operator.

Med J Malaysia Vol 61 No 1 March 2006

Dengue serology
Serum samples for dengue serology were obtained
from all children at the time of admission. The specific
antibody is based on a monoclonal antibody capture
enzyme immunoassay (MAC-EIA), which has excellent
specificity
and
sensitivity,
comparable
to
haemagglutination-inhibition test, the gold standard for
dengue serological diagnosis. The detection of dengue
specific IgM antibodies, which are produced in both
primary and secondary dengue infections, indicates
active or recent infection.
Case definitions
Patients with positive serology but did not satisfy WHO
criteria for DHF were conSidered to have dengue fever.
A diagnosis of DHF was assigned following the WHO
clinical definition on the basis of the presence of
plasma leakage and thrombocytopaenia of less than or
equal to 100,000/mm3,4. Evidence of plasma leakage
could include a peak hematocrit value of >20% above
the value at admission or discharge, clinical evidence of
pleural effusion or detection of ascitis on physical
examination. The serologic data was not used to assign
the clinical diagnosis of DHF. Patients with definitive
negative serology and who did not fulfill the WHO
criteria for DHF, were considered not to have dengue
infection.
Data analysis
The data was analyzed using Statistical Package for
Social Science (SPSS) version 10.0 software. The
criterion for determining the presence and the absence
of the dengue infection was based on confirmation by
a serological diagnosis of dengue IgM. A positive
dengue infection constitutes a positive dengue IgM,
while a negative dengue IgM represents no infection.
Therefore cases with indeterminate status in dengue
serology ~ere excluded. The outcome variable in this
study was confirmed dengue cases. The other variables
were tourniquet test and dengue IgM serology results.
While dengue IgM results confirmed the dengue cases,
the tourniquet test was evaluated for its validity and/ or
reliability as a prescriptive screening tests for dengue
infection.
The measurement of sensitivity and
specificity were used for evaluating the validity of the
tourniquet test. Sensitivity of the test is defined as the
ability of the tourniquet test to identify correctly those
who have dengue infection; on the other hand,
specificity denotes the ability of the test to ascertain
correctly those who do not have dengue infection. The
positive predictive value (PPV) of a positive test result
is the probability that a patient who gives a positive test

23

ORIGINAL ARTICLE

has a disease and the predictive value of a negative

result (PNV) is the corresponding probability that a
patient with negative result does not have the disease. 7

Results
Between June and August 2001, 79 subjects were
admitted for suspected dengue infection and thus
considered into the study. The overall male to female
ratio was 1.6:1, and the mean age of the subjects was
6.1 SD2.9 years and ranged from 0.5 to 11.6 years.
The majority of the subjects were Malays 03, 92.4 %),
followed by three Chinese and Indians respectively.
The average duration of fever before entry period was
5 days.
Of these 79 subjects, serologically positive dengue IgM
was found in 58 subjects, indeterminate status in four,
and negative serology in the remaining 17 subjects. In
the indeterminate cases, a second sample was not
obtained or the first sample was obtained too early for
definitive serodiagnosis. For diagnostic classification,
13 of the 79 subjects had dengue fever, 49 had DHF
while the remaining 17 had non-dengue infection. Of
the 49 subjects with DHF, 4 had indeterminate serology
while 45 had positive dengue IgM.
The tourniquet test was found to be positive in 65 out
of 79 subjects, including 4 subjects with indeterminate
serology. The results of the tourniquet test in the
various diagnostic categories are illustrated further in
Figure 1. Slightly more than 80% of these patients were
found positive after day four of fever, specifically
between day five to eight. This coincided with a day
or two prior to development of shock in DHF.
In the DHF group with positive tourniquet test, there
were 9 patients in DHF grade 1, 12 in grade II and 20
in grade III. On the other hand, in the negative
tourniquet test group, there was 1 in DHF I, 3 in DHF

II, 3 in DHF III and 1 in DHF IV.

Bleeding
manifestations were seen in both dengue fever and
DHF. Three patients with dengue fever presented with
petechiae (2) and gum bleeding (1). Tourniquet test
was the only manifestation of bleeding in 9 subjects
with DHF. In this group of patients, the tourniquet test
provided additional information to aid diagnosis of
DHF and this represented 18% of DHF in the study.
The tourniquet test gave positive results in 66% of
patients with confirmed dengue infection. The test was
almost as frequently positive in dengue fever (11 out of
13) as those with DHF (37 out of 41 serologically
confirmed subjects).

Evaluation of tourniquet test in dengue infection

For the above purpose, only serologically confirmed
cases were included. Hence, a total of 75 subjects were
analyzed, excluding 4 with indeterminate serology.
As shown in Table I, 48 were true positives while true
negatives were found in 4 subjects. In the remaining
23 patients, 13 and 10 subjects had false positives and
false negatives, respectively.
The validity of the tourniquet test as an indicator for
dengue infection was further evaluated. Table II shows
the sensitivity, specificity and predictive values of the
tourniquet test in the diagnosis of dengue infection.
Table II shows that the sensitivity of tourniquet test in
the diagnosis of dengue infection was 82.8% and
percentage of false negatives (which is complementary
to sensitivity) was 17.2%. The results also showed that
the specificity of the tourniquet test was 23.5% and
percentage of false positive was 76.5%. Therefore the
use of repetitive tourniquet test in the diagnosis of
dengue infection resulted in a high false positive rate.

Table I: Validity of Tourniquet Test in Dengue Infection

Present
Tourniquet test positive
Tourniquet test negative
Total

24

48
10
58

Dengue IgM
Absent

13
4
17

Total

61
14
75

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Repeated Tourniquet Testing as a Diagnostic Tool in Dengue Infection

Table II: Predictive values of tourniquet test in the diagnosis of dengue infection
Tourni uet test

82.8%
23.5%
78.7%
28.6%

Sensitivity
Specificity
Positive predictive value
Negative predictive value

45
40
35
30

III tourniquet test positive

tourniquet test negative

25
20
15
10
5
0
DF

DHF

Non-dengue
infection

Fig 1: Results of Tourniquet Test in Various Diagnostic Categories

Discussion
Many children with suspected dengue infection are not
admitted to a hospital facility but rather to a health
clinic or community practitioner where laboratory
facility to monitor a blood count is not available. In
these centres, a tourniquet test plays as an important
initial screening procedure for patients with suspected
dengue infection.
A positive tourniquet test is
considered as the only haemorrhagic manifestation in
grade 1 DHF.
Haemorrhagic manifestation is one of the essential
criteria in the diagnosis of DHF. According to WHO
classification of DHF, haemorrhagic diathesis of at least
a positive tourniquet needs to be present'. In this
study, 18% of DHF patients presented with positive
results in tourniquet test as the only bleeding
manifestation.
In other words, the test provided
additional information in the diagnosis of DHF in the
study. It should be borne in mind that the population
was a highly selected patient, in that the children were
thought to have dengue infection and were ill enough
to warrant admission. In addition, the study was
conducted in an endemic area and during the peak
season of dengue infection.

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In this study, in which quite a proportion of patients

had dengue infection, repeated tourniquet testing was
found to be not specific but reasonably sensitive. In
addition, it gave rise to a fairly high PPV of 78.7% but
at the same time was a poor negative predictor for
dengue infection. This study was carried out during
the peak epidemic season of the year where dengue
was the main cause of admission. This was .nther
corroborated by the presentation of dengue int~"clion in
three-quarter of the study population; and two-third of
those with dengue infection had DHF. An earlier study
found that a positive standard tourniquet test
repeatedly and serially performed yielded a lower PPV
of 67% and a correspondingly lower sensitivity, and a
fairly higher NPV (72%)9. It should be noted that in that
study, the proportion of patients without dengue
infection was one and a half time more compared with
dengue infection. Differences in the design of these
studies, noted above, are likely to explain the
differences in findings.
In comparison to other studies where tourniquet test
was performed once at the time of presentation in a
population of dengue/DHF patients, this study showed
that repeated and serial tourniquet testing had an

25

ORIGINAL ARTICLE

adverse effect to sensitivity and specificity values to a

single tourniquet testing5.6 Phuong et al in a large
prospective study on evaluation of the standard
tourniquet test of 548 serologically confirmed dengue
infection of hospitalised children found a high
specificity and positive predictive values of 94.4% and
98.3% respectively but sensitivity of 41.6% only5.
Similarly, in a study to evaluate the predictive value of
clinical and laboratory findings for dengue infection!
DHF in Thailand, a tourniquet test of more than 10
petechiaes combined with a flushed face and no
coryza, which were used as enrolment criteria in that
study, had a specificity and positive predictive values of
97.1% and 97.2% respectively. However, in the latter
study, no mention was made on the sensitivity.
The difference in findings could not be explained alone
by the repeated verses single tourniquet testing. Other
factors such as enrolment criteria and difference in
methodology adopted could elucidate the differences
in findings. For the current study, the serology for
dengue was not repeated on discharge from the
hospital. As a consequence, the positive predictive
value was not as high as achieved in previous studies.
This study agrees with suggestions made by Phuong et
al,6. Following admission, repeated tourniquet testing
performed on children suspected to have dengue from
an endemic area during an epidemic season, improved
its sensitivity. On the other hand it also generated
more false positive results and one possible reason for
this is repetitive tourniquet test performed on a daily
basis on the same site will induce trauma to capillaries.
In the present study, we found that children with
dengue infection were more likely to have positive
tourniquet test, compatible with other studies5.6,B,9. It
was almost frequently found positive in both dengue
fever and DHF. The test was a poor differentiator
between DHF and dengue fever.
We also found that tourniquet test was occasionally
positive in non-dengue infections. This pattern of
results was similar to that seen in several previous
studies looking at tourniquet test in dengue infection.
Kalayanarooj et al found 23 of 108 (21%) children
diagnosed with other febrile illness without a specific
bacteriological cause and negative dengue serology
had a positive tourniquet test9 . Although positive
tourniquet test suggested dengue infection, it could be
caused by other factors. Tourniquet test is a test of
integrity of capillary vessels and platelet function as

26

well as numbers. Other diseases such as scurvy,

disseminated intravascular coagulation, chronic
idiopathic aplastic anaemia, von Willebrand's disease,
anaphylactoid purpura, thrombocytopaenic purpura
and non- thrombocytopaenic purpura which affect any
of the above features may also present with positive
tourniquet test'O 11
We also found that the tourniquet test was positive if
the test was performed after day four of illness,
specifically between day five to eight. This was related
to the progression of the disease involving initially
capillary damage, followed by platelet deficiency and
dysfunction, and followed still later by defects in blood
coagulation. In DHF, capillary damage develops in the
early days of illness, and positive tourniquet test and
petechiae are early evidence of bleeding3 .
In this study, children presenting with dengue shock
syndrome, were resuscitated first before the tourniquet
test were performed. It is a known phenomenon in
DHF that as the disease progresses, tourniquet test
becomes negative when performed during the
hypotensive episode. However, after restoration of
depleted intravascular volume the test may become
positiveSl2
Although the tourniquet test has been claimed to be a
simple, convenient and readily available diagnostic
tool, it has limitations such as causing a degree of
discomfort especially in young children. For that
reason, it has been recommended for use in older
children above the age of 4 years '3 . Despite its
limitation, in health facilities where the equipment for
monitoring full blood count is unavailable for making a
diagnosis of dengue infection, particularly DHF,
tourniquet testing repeated serially would be a useful
diagnostic indicator by virtue of its high sensitivity. A
positive reading alerts clinician to consider dengue
infection as a current diagnosis in the patient and
subsequent referral to a centre which can provide good
observation and investigation facilities. Alternatively,
parents might be taught to look for specific symptoms
and asked to return daily to review signs.
The limitation of the study was the serological evidence
of dengue infection was based on a positive dengue
IgM ELISA. It is at least as specific and sensitive as the
haemagglutination-inhibition test, the gold standard for
dengue serological diagnostic test. 14. Although IgM
ELISA produces positive results in acute specimens of
secondary infections, dengue IgM may not appear until

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Repeated Tourniquet Testing as a Diagnostic Tool in Dengue Infection

the 7th day of illness in a primary infection. A second

serum sample obtained prior to hospital discharge is
required for definitive serodiagnosis; this could
attribute to a false positive result. In other words, a
child will demonstrate a positive tourniquet test in such
a situation but with a negative dengue serology result.
In conclusion, it seems that in a hospital setting, the
tourniquet test adds little to the diagnosis of dengue

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Report on dengue prevention and control: WHO, 55th

World Health Assembly, 2002 Mar 4, document A55/19.

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Halstead SB. Antibody, macrophages, dengue virus

infection, shock and haemorrhage: A pathogenetic
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Srichaikul T, Nimmannitya S. Haematology in dengue

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infection/DHF. As illustrated in this study, it aids in the

diagnosis of one-fifth of patients with DHF, who
presents with a positive tourniquet test as the only
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Used in a community, a
positive tourniquet test, repeatedly performed, is a
useful preliminary screening test in DHF as
recommended by WHO. However, it is not very
specific and has a high false positive rate.

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8.

Kabra SK, Jain Y, Pandey RM, et a!.

Dengue
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Kalayanarooj S, Vaughn DW, Nimmannitya S, et a!. Early

clinical and laboratory indicators of acute dengue illness.
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10. Simmons A. Tests useful in the evaluation of blood

coagulation. In Hematology: A combined theoretical and
technical approach. 1st edition W.B. Saunders Company
1989: 310-15.
11. Wintrobe M. Measurement of heamostatic function. In
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38(1): 71-8.
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